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Shock Flashcards

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1
Q

What is the definition of shock?

A

Tissue hyoperfusion and cellular hypoxia

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2
Q

What are the six different factors that lead to shock?

A

decreased O2 delivery, or utilization, increased O2 consumption. Hypotension below 80-90 mm Hg
Decreased systolic BP 40 mm Hg below baseline
MAP (mean arterial pressure) <60-65 mm Hg

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3
Q

What is the pathophysiology behind shock? (up to vasodilatory shock)

A

Failure to deliver and utilize O2
Increased O2 consumption (tissue demand)
Anaerobic glycolysis leads to lactate
Non-compensatory response- pathologic results

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4
Q

What is the pathophysiology of shock starting at vasodilatory shock has occurred?

A

Vasodilatory Shock- unregulated NOS, interstitial fluid, cellular edema, impaired O2 diffusion
Increased lactate-> acidosis accompanies shock
Lactate levels reflect tissue hypoxia
If D O2 fails to meet O2 demand, develop O2 debt. Cellular inflammation and injury; irreversible/ decompensated shock

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5
Q

What are the broad categories that are included in the S/S of shock?

A 
Extremities/skin
Neck veins
Heart Rate
BP
Respirations
Renal
Heart
Metabolic
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6
Q

What are the S/S of shock in the extremities/skin

A

Cool, clammy, cyanotic, pallor mottled distally, decreased perfusion/vasoconstriction, dry mucous membranes, decreased skin turgor- seen in hypovolemic, cardiogenic, obstructive shock; warm and pink extremities- associated with vasodilation of distributive/dissociative shock (cyanide position

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7
Q

What are the neck S/S of shock?

A

Neck veins: Distended (HF, PE, tamponade); flat (hypovolemic)

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8
Q

What are the hear rate s/s of Shock?

A

Fast (sensitive indicator of shock); occasionally slow

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9
Q

What are the BP S/S of shock?

A

Systolic usually low; diastolic usually low

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10
Q

What are the respiration S/S of shock?

A

Tachypnea, bronchospasm, respiratory failure

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11
Q

What are the renal symptoms of shock?

A

Receive 20% of CO oliguria; associated with vomiting, diarrhea, hemorrhage

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12
Q

What is the criteria of oliguria

A

<400-450 cc/24 hr; < 5 cc/kg/hr

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13
Q

What are the heart symptoms of shock?

A

Decreased coronary perfusion, ischemica; increased LVDP; mental status changes- decreased cerebral perfusion, confused restless, agitated, deliria, stupor, coma

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14
Q

What are the metabolic symptoms of shock?

A 
Respiratory alk (decreased pCO2, breathing), followed by met acidosis; increased glycerin, decreased glycemia, increased K, increased anion gap (non-measurable anions) (Na-(Cl+HCO3))
Frequently increased lactate/think shock; higher lactate= higher mortality
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15
Q

What are the 3 categories of hypovolemic shock?

A

Hemorrhagic
Non-hemorrhagic
DKA

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16
Q

What is the hemorrhagic version of shock?

A

GI bleeding (varices, ulcer, diverticuli), pelvic bleeding (post-partum hemorrhage, vaginal hemorrhage (laceration), hemorrhagic pancreatitis, AVM

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17
Q

What is the non-hemorrhagic cause of shock?

A

GI losses (V/D), skin losses (burns, heat strokes)

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18
Q

Discuss DKA form of shock?

A

Renal losses (salt washing, osmotic diuresis) hypoaldosternoism, adrenal insufficiency, third space loss (pancreatitis, bowel obstruction (sequestration of fluids) systemic inflammation

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19
Q

What is the most common cause of hypovolemic shock?

A

Hemorrhagic

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20
Q

What is a critical component to the presentation of hypovolemic shock?

A

Date of volume loss; helps determine acute vs slow

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21
Q

What are treatment issues with volume?

A

Tx depends on the circulating integrity (shock)- over zealous or too rapid correction
(rate of replacement composition of replacement)

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22
Q

If someone is in shock how fast should you administer fluids and what two things do you have to monitor afterwards?

A

Rx fluids fast. Monitor BP and tissue perfusion

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23
Q

Discuss crystalloids, what is the main cation, when are they useful for fluid replacement?

A

Na (main cation), used in hypovolemia from renal, GI, sweat, burns, hemorrhage

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24
Q

What is D5-W equivalent to?

A

free water

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25
When should packed RBC be administered?
for hemorrhage
26
How do we classify hemorrhagic shock?
Class I through IV
27
Discuss the criteria for class I hemorrhagic shock (including blood loss, % volume, PP, BP, Pulse pressure, RR, Urine output, mental status, fluid replacement)
``` Blood loss (ml) up to 750 ml % volume up to 15 Pulse rate (per min) <100 Blood pressure Normal Pulse pressure Normal or increased RR- 14-20 Urine output (ml/hr) >30 Mental Status Slightly anxious Fluid replacement- Crystalloid ```
28
Discuss the criteria for class II hemorrhagic shock (including blood loss, % volume, PP, BP, Pulse pressure, RR, Urine output, mental status, fluid replacement)
``` Blood loss (ml) 750-1500 % volume 15-30 pulse rate (per minute) >100 Blood pressure Normal Pulse pressure Decreased Respiratory rate 20-30 per min Urine output 20-30 ml/hr Mental status mildly anxious Fluid replacement crystalloid ```
29
Discuss the criteria for class III hemorrhagic shock (including blood loss, % volume, PP, BP, Pulse pressure, RR, Urine output, mental status, fluid replacement)
``` Blood loss (ml) 1500-2000 % volume 30-40 Pulse rate (per minute) >120 Blood pressure decreased Pulse pressure Decreased RR 30-40 Urine output 5-15 ml/hr Mental Status anxious, confused Fluid replacement crystalloid and blood ```
30
Discuss the criteria for class IV hemorrhagic shock (including blood loss, % volume, PP, BP, Pulse pressure, RR, Urine output, mental status, fluid replacement)
``` Blood loss (ml) >2000 ml % vol >40 Pulse rate (/min) >140 Blood pressure decreased Pulse pressure Decreased RR >35 Urine output (ml/hr) negligible Mental Status- confused, lethargic Fluid replacement crystalloid and blood ```
31
What if someone's blood pressure doesn't improve after giving fluid (for a hypovolemic shock)?
Continue with fluids and add a vasopressor
32
Describe the two forms of distributive shock?
Septic or non-septic (vasodilation)
33
How common is distributive shock?
Most common form of noncardiogenic shock
34
What is the mortality rate of distributive shock?
29-46%
35
What is sepsis criteria?
Fever, Tachy, increased RR, increased WBC (you need two or the four plus a suspected source of infection)
36
What are some common sources of infection?
Pulmonary (pneumonia, emphysema), abdominal (peritonitis, cholangitis), GU (pyelonephritis, abscess), CNS (meningitis), Skin (cellulitis, necrotizing fasciitis)
37
What are the criteria for septic shock?
If there is severe sepsis you have a decreased BP (<90 systolic or >40 mmHg and decreased baseline)
38
Describe the septic shock pathophysiology up to (and including) the action of microorganisms
Tissue hypoxia activates inflammation Endothelial injury- release NO2 potent vasodilator Mediators of sepsis-endotoxin Cytokines (IL-6, TNFa) Nitric oxide Microorganisms activate innate, adaptive, endothelial immune responses and coagulation
39
Describe the septic shock pathophysiology after the action of microorganisms
Endothelial injury- becomes permeable to leak fluids into tissue (lung, intestine, capillary leak) release NO2, potent vasodilator decreased preload Distributive- abnormal distribution of systemic blood flow In addition to vasodilation/microvascular vasoconstrictive tissue hypoxia increased lactate
40
What are some S/S of septic shock?
Extremities/skin- warm, flushed (vasodilator) Heart rate- fast; 10-30% have myocardial depression BP- low (<90 systolic BP) Neck veins- flat Mental status changes Renal Clinically- hypovolemic, vasodilation, impaired tissue O2 use (dissociative shock)
41
What are the distributive hemodynamics with septic shock (vasodilatory)
Decreased BP, decreased JVP/decreased CVP, decreased SVR Increased HR, Increased CO, PAOP decreased Extremities warm Lungs dry Tissue perfusion (mixed venous (SVO2 oxyhemoglobin sat) >65%
42
How do we dx anaphylactic shock?
Clinically
43
What are the sx of anaphylactic shock?
Cutaneous (urticaria, oral-facial angioedema, hives, flushing, pruritus) Respiratory (dyspnea, cough, wheezing, stridor) Abdominal (cramping, pain) Vascular (decreased BP, chest pain, arrhythmias)
44
What is a life-threatening/danger signal in anaphylactic shock?
Rapid progression of sx
45
What is respiratory distress (in the context of anaphylactic shock)?
stridor, persistent cough, wheezing, hypotension
46
What is the pathophysiology of septic shock?
Type I IGE mediated (immediate) hypersensitivity; mast cells release cytokines, histamine, tryptase Vasodilation, vascular permeability, visceral smooth muscle contraction, tissue inflammation
47
What are some tx for anaphylatic shock
Oxygen, Ivs for saline bolus Epinephrine If bronchospasm- albuterol Methylprednisolone
48
How does the distributive hemodynamic profile of anaphylactic shock compare to that of septic shock?
``` It is the same PAOP N(early) or decreased (late) Decreased or increased CO Decreased SVR Tissue perfusion >65% ```
49
What is the definition of cardiogenic shock
Decreased systemic O2 delivery; deterioration of cardiac dysfunction due to myocardial, valvular, structural, toxic or infectious
50
What does inadequate cardiac pumping lead to (cardiogenic shock)?
``` Decreased BP (<90 or > 30 mm Hg below baseline) Decreased CO, decreased UO ```
51
What would you expect of other lab values including Cl, PCWP, EF, SVR Tissue perfusion during cardiogenic shock?
``` Cl < 22 Increased PCWP Decreased EF SVR Decreased Tissue perfusion <65% ```
52
What are the 3 broad categories of cardiogenic shock
Cardiomyopathic, arrhythmogenic | Mechanical
53
What falls into the category of Cardiomyopathic cardiogenic shock
MI, myocarditis, cardiomyopathy, exacerbation of severe HF
54
What falls into the category of arrhythmogenic cardiogenic shock
Tach (A fib, flutter, re entrant tach, brady (complete heart block, Mobitz (2nd degree
55
What falls into mechanical?
Severe AI or MR; acute valvular rupture (papillary or chordae teninea rupture, abscess) Critical AS, VSD, rupture vent wall aneurysm, atrial myxoma
56
What are some Clinical signs of cardiogenic shock?
Decreased blood pressure, decreased urinary output, AMS Cool, mottled extremities Distended neck veins Pul edema
57
What is the most common etiology of Cardiogenic shock
LV failure secondary to AMI, acute MR, VSD, RV infarction, ventricular wall rupture (tamponade)
58
What is the pathophysiology of cardiogenic shock?
Failure to pump SV and CL Increased SVR Increased cyotkines
59
What is the mortality rate of CS
~40-50%
60
How long does it take for a CS to develop s/p STEMI
7-10 hours

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